Hep C Flashcards
Hep C background
- RNA virus
- 6 major genotypes
- Type 1 is the most common
Hep C epidemiology
- Speed and progression is affected by co-infection with HIV and alcohol use
- 5x as wide spread as HIV
Risk factors for Hep C
- Being a baby boomer (1945 to 1965)
- IDU
- Transplant patient
- Birth from HCV mother
First HCV epidemic
- 1960s to 1980s
- Peak deaths between 2030 and 2035
- Most likely due to iatrogenic causes (health care)
- NOT drug use
Second HCV epidemic
-Due to rise in injection drug use
Diagnosis of HCV
- Antibody test to identify exposure
- HCV RNA needed to determine if chronic infection
- HCV Ab positivity does not confer immunity
Evolution of HCV therapy
1) Interferon based
- Long treatment (up to 1yr)
- Major toxicities
- Many patients are scared of this therapy
2) Direct acting antivirals (DAAs) first appearance in 2011
- Standard of care
DAA treatment guidlines
- 8 to 12 weeks of therapy for all patients with OUT cirrhosis
- 12 weeks for patients WITH cirrhosis
DAA ending and site of action
1) NS3/4A -previr
2) NS5A -asvir
3) NS5B -buvir
Do you use DAAs as monotherapy?
- NO, must be used in combination
- Monotherapy will cause treatment failure/ resistance
- All DAAs have warning for HBV reactivation
Glecaprevir/ Pibrentasvir (GLE/PIB)
- Mavyref
- Duration 8 to 16 weeks (dependent on pt)
- Can be used in renally insufficient pts
- Don’t use in decompensated cirrhosis
- Will mess up your oral birth control
Ledipasvir/Sofosbuvir (LDV/SOF)
- Harvoni
- One tablet, once a day
- Duration is usually 12 weeks
- Cirrhosis (24 weeks or 12 weeks with ribavirin)
- Can be used in ages 12 years and up
- Do not use in pts with CrCl<30ml/min
- Needs acidic enviorment
Sofosbuvir/Velpatasvir (SOF/VEL)
- Epclusa
- 12 week therapy
- 1 pill once daily
- Needs acidic enviorment
- Avoid PPIs and H2 blockers (12 hrs of separation)
Sofosbuvir/Velpatasvir/Voxilaprevir (SOF/VEL/VOX)
- Vosevi
- Used when previous DAA therapy failed
- 1 pill once a day
- Diarrhea = main side effect
Elbasvir/Grazoprevir (ELB/GZR)
- Zepatier
- 1 tablet once a day
- Need to test for resistance first (GT1a)
- No resistance use for 12weeks
- Yes resistance use for 16weeks with ribavirin
Ribavirin
- MoA not well understood
- Has synergistic effects
- Inhibits viral replication
- Not effective as monotherapy
- Weight base dosing
Side effects of Ribavirin
- Anemia
- Twice daily dosing to help decrease nausea
- Teratogen = avoid in pregnancy (don’t get pregnant for 6mo after therapy)
General lab abnormalities with all DAAs
- Very few lab abnormalities
- Headache is most common side effect
- Fatigue is second
Key points for drug interactions
- Use hepdruginteractions.org
- Amiodarone = bradycardia
- Acid suppressive therapy (LDV and VEL)
- Avoid ethinyl estradiol in GLE/PIB
- Avoid all herbals
- Avoid major CYP inducers (rifampin)
General management of all viral hepatitis patients
- Minimize further liver damage
- Vaccinate for Hep A, B, yearly flu, and pneumococcal vaccine
- Avoid alcohol
- Minimize smoking
- Loose weight (if over weight)
How to take care of Hep pts with cirrhosis
- Screen for liver cancer q6mo
- Evaluate esophageal varices
- Avoid hepatotoxic drugs
- Avoid all NSAIDs (aspirin, ibuprofen, naproxen) due to increased risk of bleed
- Impaired response to diuretics
